Information campaigns and trained triagists may support patients in making an appropriate choice between GP and emergency department.

Sir,

The recent findings of Henninger et al. [1], are similar to the results of our research in Belgium starting from 2003, despite obvious differences in health care services [2,3]. Based on semi-structured interviews of adults with non-vital medical problems, Henninger et al., describe three main areas in the decision making of the patients to consult either a general practitioner (GP) or an emergency department (ED): the quality of the relationship with their GP, the perceived nature of the complaint and expected waiting times. In addition to the findings of Henninger et al., we found in our qualitative assessment of patients’ choices, that patients also had great trust in their GP, and that people are loyal to the service they have experience with. However, patients stressed that they were in doubt when deciding upon which service to use for which medical problem. They mentioned that professional caregivers could advise them concerning the most appropriate service [2,3].

As an implication of their study, Henninger et al., suggest that the solution to promote GP surgery as first entry is to be found in an increased availability of GPs during day-time working hours. Although we fully agree that patients appreciate the care they are acquainted with, and in particular the availability of their own GP [3], we think that this alone is not going to solve the problem. In Belgium, GPs are available 24/7. Implementing an out-of-hours GP cooperative (GPC) next to the ED, has showed not to decrease overuse of the ED [4].

Governments and health care facilities try to redirect patients towards primary care, in order to work more efficiently and cut costs. So, enhancing the availability of GPs during working hours is a logic focus to work on. To evaluate further interventions like increasing the number of GPs, valid data are required to correctly evaluate the effectiveness of different approaches. Therefore, we established iCAREdata [5]. This clinical research database on out-of-hours primary care is updated on a weekly basis and currently covers a population of 1.8 million people. iCAREdata provides quasi real-time data on contacts at GPCs in Flanders/Belgium on its portal site (https://icare.uantwerpen.be). iCAREdata also processes patient contacts at the ED, enabling researchers to study effectiveness of interventions on a weekly basis. Changing availability of GPs during intervention and control weekends is a method that might deliver rapid results of changes in patient flows in general practice and the ED.

As a continuation of our earlier research on patient choices, we are currently assessing the effects of triage systems at the ED on changes in patient flow using iCAREdata [2-4,6]. In a pilot study, we already tested the effect of an information campaign in the ED waiting room, helping patients to consider seeking help at the GPC for certain medical problems. We monitored a small but statistically significant change in patients relocating from the ED to the GPC of 1.7% to 5.4% (p < .01) that remained stable during ten months. This indicates that informing patients could have an influence on choice of service. In the ongoing TRIAGE-trial (ClinicalTrials.gov Identifier: NCT03793972) a trained triage nurse at the ED will advise eligible patients to seek help at the GPC instead of staying at the ED [7]. First results show that this is probably a safe solution and patients experience the professional advice of the triage nurse as reassuring.

Improving accessibility of primary care might be relevant, but will not be sufficient. The decision making of patients could be improved by informing them about the available services and when to use them. Triage by a medical professional may enable safe changes in patient flow.